OM(I)G! New York Medicaid Case Mix Audit Success

OM(I)G!New York Medicaid Case Mix

Audit Success

HARMONY UNIVERSITYThe Provider Unit of

Harmony Healthcare International, Inc. (HHI)

Presented by:Barbara Patterson-Paul, Regional Consultant Terese Cargen, Field Operations and Regional

Consultant

Regional Consultant for Harmony Healthcare International, Inc.Over 30 Years Experience in Nursing with a Focus on Long-Term CareSpeaker has Provided Extensive Training for Members of the Inter-disciplinary Team on MDS, Reimbursement, and Management SkillsOver 16 Years in Management of an Acute Rehabilitation HospitalHospital Performance Improvement, Quality Assurance Program, with expertise in preparation for JCAHO, CARF and DOH SurveyCertification in Rehabilitation Nursing (CRRN)

Speaker Bio (Barb Patterson)

Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 2

Harmony Healthcare International, Inc. 3

Speaker Bio (Terese Cargen)

Field Operations and Regional Consultant for Harmony Healthcare International, Inc.Over 18 years of experience in the Long-term Care

OTR/L, RAC-CTOccupational TherapistRehab management/ Consulting therapist Trainer for advanced Clinical Strategies. Expert in NYS Case Mix Reimbursement and ComplianceMedicare Part B Program DevelopmentKnowledge in Medicare/ Medicaid documentation and Compliance

Copyright © 2013 All Rights Reserved

OM(I)G!New York Medicaid Case Mix Audit Success

Disclosures: The planners and presenters of this educational activity have no relationship with commercial entities or conflicts of interest to disclosePlanners:

Elisa Bovee, MS, OTR/LDiane Buckley, BSN, RN, RAC-CTBeckie Dow, RN, RAC-MTKeri Hart, MS CCC, SLP, RAC-CTKristen Mastrangelo, OTR/L, MBA, NHAChristine Twombly, RNC, RAC-MT, LHRM

Presenter:

Barbara Patterson-Paul, Regional Consultant Terese Cargen, Field Operations and Regional Consultant


Harmony Healthcare International, Inc.

OM(I)G!New York Medicaid Case Mix Audit SuccessDisclosure Speaker: Barbara Patterson-Paul, Regional Consultant Terese Cargen, Field Operations and Regional

Consultant

The speaker has no relevant financial relationships to disclose

The speaker has no relevant nonfinancial relationships to disclose


Harmony Healthcare International, Inc.

OM(I)G! New York Medicaid Case Mix Audit SuccessCriteria for Successful Completion

Complete Sign-in and Sign-Out on Attendance FormAttendance for entire sessionCompletion and submission of speaker evaluation form.


Housekeeping


OM(I)G! New York Medicaid Case Mix Audit SuccessObjectives

The learner will be able to identify the specific components of NY RUG-III 53 categories.The learner will be able to identify high risk NY RUG-III 53 categories.The learner will be able to identify documentation requirements to support the RUG components.The learner will be able to identify strategies for organization of the Medical Record in preparation for OMIG Audits.

Copyright © 2013 All Rights Reserved 8Harmony Healthcare International, Inc.

OMIG Audits

NY noted an increase in CMI from Jan 2011 to Jan 2012 of 6%, equating to $200 million Cap of 5% for facilities with a significant increase in CMI

Increase over 5%, they would receive the balance of payment beyond the 5% cap following an audit.304 Homes met the criteria


OMIG Audits

January 2012 Roster304 Homes had an increase of 5%+OMIG’s plan was for 90 Homes to be audited by mid MarchThe remaining 214 Homes by July


OMIG Audits

June 2013 Dear Administrator LetterUpdate on Case Mix Audits and Rates released.

79 facilities were reviewed58 had no decrease in CMI21 facilities had a decrease in CMISome facilities had a decrease in CMI of over 10%


OMIG Audits

Following the first audit sample of 79 facilities, DOH released rate adjustments reflecting the full Case Mix on August 14, 2013.DOH also announced the January 2012 census audits would continue and be combined with July 2012 census to process the audits more quickly.


OMIG Audits

171 facilities remained to have both their January 2012 and July 2012 census audited.An additional 79 facilities to be reviewed for July 2012.250 facilities to be audited with each Case Mix census submission.


OMIG Audits

OMIG updated their audit protocol.Additionally, OMIG announced they would review BMI, Dementia, and Payor responses.Hiring of Nurses to augment their staff.All Nurses to be RNs with MDS 3.0 training and OMIG audit training.Educational resources on MDS/Case Mix will be available to facilities in the future.


OMIG Audits

Post Audit the facility’s CMI will be recalculatedThe Medicaid Rate will be recalculated based on the new CMIMDS 3.0 RAI InstructionPer OMIG, some issues require the auditors interpretation


Audit Process

Notified by mail 3 to 5 Days prior to scheduled Audit Date

List of residents records to be auditedAudit complete in 1 to 2 Days

Auditors will review what is provided to them

May request additional information

An exit conference with review of findings will be conducted at the end of the visit


Audit Process

Written report of findings will be left on site

Draft report will be received within 30 days

Fax Number will be provided at the end of the visit

Additional information to support the RUG can be faxed within 30 days of the audit

Final ReportCan appeal based on information already sent


High Risk NY RUG-III 53

“If 1 or 2 items were corrected the RUG Score would change” Critically important to understand how the RUG was derived in order to ensure that all data to support the RUG is on file and readily available to auditors


Observed High Risk NY RUG-III 53

CategoriesExtensiveRehab

Change from previously submitted October PD1January SSC

Modified MDSsADL one point into the next category

CC1SSC

l


Organization of the Record


Ensure all staff are on the look out for the letterIdentify RUG Qualifiers associated with the medical record auditors have identified



Develop a team that will collect and Review the information needed

Medical RecordsMDSRehabDON

Audit ahead your self ahead of time



Know the RUG qualifiers that achieved the RUG. Where is the documentation located?Ensure all documentation to support RUG components are accessible to auditorsEnsure all documents have the residents name and date/month visible on copies Prompt response to Auditor requests

30 days if unable to locate

Work as a TeamCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 23

Tips for Organization of the Record

MDS Notes: In System or handwritten identifying where information is located for less obvious codingProcess for physician documented DiagnosisCopying acute care documentation specific to coding and keeping in specific section of the medical record. (i.e. IV meds while in hospital)Ensure Therapy logs are one file at the end of each monthEnsure ADL Flow Sheets are on file in the medical record to support ARD periodCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 24


Prepare packets for auditors with only the information necessary to support the RUG.OMIG auditors have requested that facilities not provide them with the entire medical record.



Care PlansSome auditors are requesting Care Plans and some are not.How does the RUG score relate to daily care needs? Is the resident receiving PT for difficulty walking and the Care Plan reflect “ambulates independently throughout unit”?



Care PlansIs patient coded as having hemiparesis, generating a clinically complex RUG score without hemiparesis documented as a problem on the care plan with interventions to address?


Areas of Focus During OMIG Audit

ADL sCNA Flow sheets and electronic trackers.Major area of focusAdjustment in ADL Coding may significantly impact payment.Component of every RUG score.Most OMIG auditor findings appear to be ADL coding errors.



Rehabilitation RUGArea of greatest riskSignificant impact on CMIRHC versus PD1, 1.40 vs. .72, a difference of .68 points.Follow Medicare Part B guidelines for documentation.Consider appealing if coverage allowed by Medicare Part B but denied by OMIG.



Rehabilitation RUG (cont)Nursing documentation should reflect a change in condition or new limitation warranting the need for skilled therapy.

For example: “Patient is requiring increased assistance with meals due diagnosis of Parkinson’s disease causing hand tremors. Patient expresses a desire to maintain her functional independence. Recommend OT evaluation to assess need for adaptive feeding devices.”



Example: “Patient’s upper respiratory infection has resolved, however, patient has been unable to regain prior functional level due to prolonged illness with reduced strength and mobility. Recommend PT/OT evaluations to address functional decline in ADLs and mobility.”

Example: “Patient noted with knees buckling daily when CNAs ambulate patient to the toilet.”

Example: “Patient noted with excessive chewing prior to swallowing during meals.”



Therapy documentation should describe the reason for referral, change from prior level of function, and skilled interventions needed.


OMIG Interpretation/Sample Findings

Patient #1

MDS with ARD of 5/10/12 has transfer self performance as a 4, total dependence. CNA tracker for 5/10/12 @1:40pm has extensive assist. Level 4 needs to be every time event occurs.



Patient #2

MDS with ARD of 1/9/12 has restorative PT/OT modalities. There was no decline noted in resident’s condition which indicated a significant change in condition which required restorative therapies.



Patient #3Eating: MDS with an ARD of 11/23 self performance = 3. CNA ADL tracker indicates independent. MDS Coordinator has indicated that this resident is tube fed. Although there was documentation provided to support tube feedings, there was no documentation to support that there was one person doing the tube feeding.



Patient # 4

The MDS with an ARD of 1/24/12 has a 3 for self performance of bed mobility. The facility ADL tracker for the week of 1/18 – 1/24 indicates a self performance of 2.



Patient # 5

MDS with ARD of 11/15/11 has no supporting documentation of behavior problems.



Patient #6MDS with ARD of 1/16/12 had 2 days of MD visit and 2 days of order change. Documentation indicates 1 day of order change.

Patient #7PT 166 minutes claimed, 143 minutes of documented treatment.



Patient #8MDS with ARD of 1/15/12 has a RUG score of RVC. There is no documentation of a physician’s order for Physical Therapy or Speech Therapy. There is no evaluation or reassessment documented for PT, OT, or SLP.



Patient #9MDS with ARD of 1/6/12 has restorative PT. Record review shows resident was placed on PT one day before the start of the ARD look back due to lack of coordination, muscle weakness, and difficulty walking. There was no decline in level of function which caused a significant change in status necessitating a restorative modality.



Patient #10MD Order Changes: 5/4/12 order clarification and 5/7/12 order dosage change are not considered new orders when dose is changed or clarified.


Component of a RUG

RUG-III Grouper Qualifications:

Identification of Qualifiers and Extensive


RUC PD21st Position

Major RUG-III Classification Categories R=Rehabilitation P=Reduced Physical

2nd Position 1st End Split Rehab RUG Level Nursing ADL split Lower 18 U=Ultra High D= ADL

3rd Position 2nd end split Rehab ADL Nursing depression or restorative end split Extensive Rehab C=Highest ADL split 2=Restorative

Component of a RUG

Component of a RUG

Know qualifiers of the RUGAudits have been highly focused on the technical components of the RUG

Expect clinical focus as auditors learn the process

Documentation must be on file to support each component or qualifier of the RUG


Extensive Component of RUG:

Non-Therapy ExtensiveSE1SE2SE3

Rehab ExtensiveR_XR_L


Extensive Defined

Extensive Services qualification based on ADL Sum 7 or greater and one of the following services:

IV feeding in last 7 daysIV medications in last 14 daysSuctioning in last 14 daysTracheostomy care in last 14 daysVentilator/respirator in last 14 days

Special Care with ADL score 6 or less


Extensive Defined

While a ResidentTreatments, procedures, and programs received or performed by the resident after admission/re-entry to the facility and within the 14-day look-back period

While not a ResidentTreatments, procedures, and programs received or performed by the resident prior to admission/reentry to the facility and within the 14-day look-back period


IV Parenteral/IV Feeding Defined

K0510A1 and K0510A2 includes any and all nutrition and hydration received in the last 7 days provided they were administered for nutrition or hydration “Supporting documentation that reflects the need for additional fluid intake specifically addressing a nutrition or hydration need. This supporting documentation should be noted in the resident’s medical record according to State and/or internal facility policy.”



DO:Administered for nutrition or hydrationIV fluids or hyperalimentation, including total parenteral nutrition (TPN), administered continuously or intermittently IV fluids running at KVO (Keep Vein Open) IV fluids contained in IV Piggybacks Hypodermoclysis and subcutaneous ports in hydration therapyPrevent dehydration if the additional fluid intake is specifically needed for nutrition and hydration



DO NOT:IV fluids NOT administered for nutrition or hydrationIV fluids administered solely as flushes. In conjunction with Dialysis, Chemotherapy, Surgical procedure or Diagnostic procedureIV fluids used to reconstitute and/or dilute IV medications


IV Medication Defined

Code any drug or biological given by intravenous push, epidural pump, or drip through a central or peripheral port in this item

Do not include IV medications of any kind that were administered during:

Dialysis

Chemotherapy

Surgical procedure Diagnostic procedure


IV Medication Defined

Do not code flushes to keep an IV access port patent

Do not code IV fluids without medication here. Dextrose 50% and/or Lactated Ringers given IV are not considered medications

Epidural, intrathecal, and baclofen pumps may be coded

Subcutaneous pumps may not be coded


Extensive Defined

May code treatments, programs and procedures that the resident performed themselves independently or after set-up by facility staff in Section O

Tracheostomy careSuctioning


RUG-III: Extensive Services Count

RUG III Non-Therapy SE Count:

Parenteral IV – K5A = 1IV Medication – P1ac = 1Special Care = 1Clinically Complex = 1Impaired Cognition = 1


RUG-III: Extensive Services Count

Extensive Count RUG-III Class 4 or 5 SE3 2 or 3 SE2 0 or 1 SE1


Extensive Services Documentation

Facility Medication Administration Records for IV Medication and IV HydrationHospital Medication Administration Records for IV Medication and IV HydrationEmergency Room RecordsHospital documentation evidencing actual administration of for IV Medication and IV Hydration


Additional Documentation to Support

IV Hydration facility administeredDietary notes to support administration for hydrationCare Plan supporting Dehydration risk

MDS Notes indicating location of the data

MDS System may allow MDS Note in MDS

Staple a copy of documentation to support to printed MDS or MDS SignatureScan document into Electronic Medical Record


Component of a RUG

RUG-III Grouper Qualifications: Depression,

Diagnosis and Rehab

Depression Component of a RUG

End Split for Clinically Complex :

CD2 versus CD1

2= Positive Depressive Indicator


Depressive Indicator Defined

Depression End Splits: Signs and symptoms of depression are used as a third-level split for the Clinically Complex category

D0300 PHQ-9 Total Severity Score is greater than or equal to 10 but not 99

or D0600 PHQ-9 Total Severity Score is greater than or equal to 10


Depressive Indicator Documentation

Section D of the associated MDS

D0300 PHQ-9 Resident InterviewD0600 PHQ-9 Staff Interview


Diagnosis Coding Component of a RUG

Special CareMultiple SclerosisCerebral PalsyQuadriplegia

Clinically ComplexComaHemiparesis Diabetes (with daily injections and order Changes)


Diagnosis Coding Component of a RUG

Special CareDehydration (with Fever)Pneumonia (with Fever)

Clinically ComplexSepticemiaDehydrationPneumoniaInternal Bleed


Diagnosis Coding Defined

Require a physician-documented diagnosisActive diagnosis:

Direct relationship to the resident’s current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period



Medical record sources for physician diagnoses include:Progress notes, the most recent history and physical, transfer documents, discharge summaries, diagnosis/ problem list, and other resources as available If a diagnosis/problem list is used, only diagnoses confirmed by the physician should be entered


Diagnosis Defined

Hemiparesis: Includes Hemiplegia Must have a specific diagnosis Weakness due to CVA is not supportiveQuadriplegia: Excludes Quadriparesis Clarified on Open Door Forum February 2013: Must be related to spinal cord injury. Excludes Functional Quadriplegia.


Diagnosis Defined

Dehydrated (two or more present)

1) Intake less than 1,500 ml of fluids daily2) Clinical indicators: dry mucous membranes,

poor skin turgor, cracked lips, thirst, sunken eyes, dark urine, new onset or increased confusion, fever, or abnormal laboratory values (e.g., elevated hemoglobin and hematocrit, potassium chloride, sodium, albumin, blood urea nitrogen, or urine specific gravity, etc.

3) Resident’s fluid loss exceeds intake Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 67

Diagnosis Defined

Internal Bleed: Frank Bleeding or Occult (such as guaiac positive stools). Vomiting “coffee grounds,” hematuria (blood in urine), hemoptysis (coughing up blood), and severe epistaxis (nosebleed) that requires packing.

Excludes Menses or a urinalysis that shows a small amount of red blood cells


Diagnosis Defined

Coma (Persistent Vegetative State): Diagnoses by a Physician

Excludes progressive neurologic disorders or severe cognitive impairment as they are usually not comatose or in a persistent vegetative state



Active Diagnosis: Do not include conditions that have been resolved, do not affect the resident’s current status, or do not drive the resident’s plan of care during the 7-day look-back period, as these would be considered inactive diagnoses Medical treatmentsMedication Symptoms


Diagnosis Component Documentation

Physician Orders (Monthly/ Interim)Physician Signed in the last 60 days

Physician Progress NotesEmergency Department ReportHistory and Physical

Documentation must support diagnosis is active

Diagnosis list must be supported by Physician

Physician Order or SignatureSupported by relationship in the Care Plan


Accurate Diagnosis Coding Tips

What is the facility process for adding and resolving diagnosis to the medical record?

Supported by PhysicianPhysician Orders

Diagnosis lists alone do not support if not signed and dated by the physicianWhat is the facility process for identifying resolvable diagnosis

Pneumonia


Rehab Component of a RUG

Extensive Rehab“X” or “L” in last position

Combination of Rehab and the Extensive serviceBased on actual minutes of Physical, Occupational and Speech Therapy minutes combined during the 7-Day Look-back period


Rehab RUG Levels Defined

Ultra High Intensity Criteria: 720 minutes or more (total) of therapy per week ANDAt least two disciplines, 1 for at least 5 days, AND 2nd for at least 3 days

Very High Intensity Criteria: In the last 7 days:

500 minutes or more (total) of therapy per week ANDAt least 1 discipline for at least 5 days



High Intensity Criteria (either (1) or (2) below may qualify)

325 minutes or more (total of therapy per week AND At least 1 discipline for at least 5 days

Medium Intensity Criteria (either (1) or (2) below may qualify)

150 minutes or more (total) of therapy per week AND at least 5 days of any combination of the 3 disciplines



Low Intensity Criteria (either (1) or (2) below may qualify):

(45 minutes or more (total) of therapy per week AND At least 3 days of any combination of the 3 disciplines AND 2 or more nursing rehabilitation services* received for at least 15 minutes each with each administered for 6 or more days


RUG III Leveled Rehab ADLs Splits

REHAB RUG-III RUG-III ADL Score Class 15 – 18 R_C 8 – 14 R_B 4 – 7 R_A

REHAB RUG-III RUG-III Extensive Class 16-18 R_X 7-15 R_L


Rehab RUG Documentation

Actual Minutes supported by Therapy logs

Actual Minutes not unitsLegiblePatient name

Rehabilitation Nursing (Restorative) minutes provided for Rehabilitation LowMinutes signed by the therapist that provided carePhysician Orders for therapy



Reason for Referral Supported by Nursing and or Physician DocumentationPrior Level of Function supported by Medical record Change in status supported by medical record:

NursingADL


Component of a RUG

RUG III Grouper Qualifications: Restorative

Nursing, Procedures, Treatments and Conditions

Rehab Nursing Component of RUG

End Split is restorative nursing rehab/restorative 6 days in 2 areasReduced Physical/Behavioral /Cognitive

BB2 versus BB1PB2 versus PB1

Rehab LowRLARLB



2 areas for 15 or more minutes a day for 6 or more of the last 7 days:

H0200C, H0500** Urinary toileting program and/or bowel toileting program O0500A,B** Passive and/or active ROM O0500C Splint or brace assistance O0500D,F** Bed mobility and/or walking training



Restorative (Continued)O0500E Transfer training O0500G Dressing and/or grooming training O0500H Eating and/or swallowing training O0500I Amputation/prostheses care O0500J Communication training


Rehab Nursing Documentation

Signed logs supporting days 15 minutes provided Signed logs supporting 2 areas provided 6 days



RAI criteria for rehabilitation nursing must be met:

Measurable objective and interventions must be documented in the care plan and in the medical record Evidence of periodic evaluation by the licensed nurse must be present in the medical record



Nursing SupervisionState specificMinimum 30 Days

Does not include groups with more than four residents per supervision helper or caregiverEvidence of Restorative Nursing Aid training


Skin Component Defined

Special Care2 Stage I or II Pressure Ulcers or Venous/Arterial ulcers (crosswalk)Stage III, IV or Unstageable Pressure UlcerOpen lesionSurgical wound

Clinically ComplexBurnsFoot infection/wounds


Skin Component Defined

Pressure Ulcers require 2 or more skin treatmentsSurgical wounds and open lesions require 1 treatment


Documentation to Support Skin

Weekly sizing and staging reports or nursing note evidencing present in the 7-day Look-back periodTreatment sheets to support treatment administered in the 7-day Look-back periodDocumentation to support the highest stage the pressure ulcer was if healingWound Care Consult Reports


Skilled Procedures and Treatments

Special CareTube feeding and Fever or AphasiaRadiation treatmentRespiratory therapy =7 days

Clinically ComplexDialysisOxygen therapyTransfusions


Skilled Procedures and Treatments Defined

While a ResidentTreatments, procedures, and programs received or performed by the resident after admission/re-entry to the facility and within the 14-day look-back period

While not a ResidentTreatments, procedures, and programs received or performed by the resident prior to admission/reentry to the facility and within the 14-day look-back period



Oxygen: 14-Day Look-backOxygen actually administered in the Look-back PeriodPRN order must have documentation to support actual administrationContinuous oxygen with documentation evidencing administered



Tube Feeding: 7-Day Look-backActual intake through parenteral or tube feeding routesProportion of total calories received 51% or more or 26% to 50% and greater than 501 cc Average Fluid Intake per Day Documentation in the Look-back period to support for patients eating and receiving tube feed


Respiratory Therapy

Respiratory therapy services are for the assessment, treatment, and monitoring of patients with deficiencies or abnormalities of pulmonary function. Respiratory therapy services include coughing, deep breathing, heated nebulizers, aerosol treatments, assessing breath sounds and mechanical ventilation.RAI Manual Appendix A November 2012


Skilled Procedures and Treatments Documentation

Facility Medication/Treatment Administration Records Respiratory Flow SheetsHospital Medication/Treatment Administration RecordsEmergency Room RecordsConsult ReportsNursing Notes


Conditions Component of the RUG

Special Care: Fever in conjunction with any of the following:

Dehydration Tube Feed, Weight Loss Vomiting


Conditions Defined

7-Day Look-Back PeriodFever: Defined as a temperature 2.4 degrees F higher than baseline. The resident’s baseline temperature should be established prior to the Assessment Reference Date.Vomiting: Regurgitation of stomach contents; may be caused by many factors (e.g., drug toxicity, infection, psychogenic)


Conditions Defined

Weight Loss:Includes weight loss either physician-prescribed or not physician-prescribedWeight loss of 5% or more in the past 30 days or 10% or more in the last 180 daysCompare the resident’s weight on in the 7-day look-back period to his or her weight in the observation period 30 and 180 days ago. New Admissions ask the resident, family, or significant other and consult. Review transfer information.


Conditions Documentation to Support

Weight RecordsVital Signs trackingNursing NotesFacility Medication/Treatment Administration Records Hospital Medication/Treatment Administration RecordsEmergency Room RecordsConsult ReportsMust support the actual date the condition occurred



Accuracy of Weight:Most recent weight measure in the last 30 days If the last recorded weight was taken more than 30 days prior to the ARD of this assessment or previous weight is not available, weigh the resident again. If the resident’s weight was taken more than once during the preceding month, record the most recent weight


Physician Orders and Visits Component

14-Day Look-Back PeriodClinically Complex:

2 Days of Physician Orders and 2 Physician Visits4 Days of Physician Orders and 1 Physician Visit

Diabetes mellitus and injection 7 days and 2 Physician days of order changes


Physician Visits Defined

Physician Visit: Includes medical doctors, doctors of osteopathy, podiatrists, dentists, and authorized physician assistants, nurse practitioners, or clinical nurse specialists working in collaboration with the physician as allowable by state lawExamination (partial or full) can occur in the facility or in the physician’s office. Included in this item are telehealth visits as long as the requirements are met for physician/practitioner type as defined above and whether it qualifies as a telehealth billable visit claims proessing manual.


Physician Visits Defined

Do not include physician examinations that occurred prior to admission or readmission to the facility (e.g., during the resident’s acute care stay)Do not include physician examinations that occurred during an emergency room visit or hospital observation stay Off-site (e.g. while undergoing dialysis or radiation therapy) with documentation of the physician’s evaluation


Physician Orders Defined

High Audit AreaPhysician Orders: 14-Day Look-back Period in Section O:

Days of Order changes not the actual numberMedical doctors, doctors of osteopathy, podiatrists, dentists, and physician assistants, nurse practitioners, or clinical nurse specialists working in collaboration with the physician as allowable by state law. New or altered treatment



Excludes:Orders prior to the date of admission or re-entryOrders for activation of a PRN order A sliding scale dosage schedule that is written to cover different dosages depending on lab values, does not count as an order change simply because a different dose is administered based on the sliding scale guidelines (Coumadin)Orders for transfer of care to another physician



Excludes:Standard admission orders, return admission orders, renewal orders, or clarifying orders without changesOrders on day of admission with unexpected change/deterioration in condition or injury are considered as new



“Orders written to increase the resident’s RUG classification and facility payment are not acceptable”

An order written on the last day of the MDS observation period for a consultation planned 3-6 months in the future should be carefully reviewed.


Documentation to Support

Accurate Counting of Days (not number of orders)Physician orders legibly datedInterim and Monthly orders sheetsPhysician progress report and consultsMust evidence at least partial assessment

Nursing documentation that a visit occurred is not sufficientCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 108

Component of a RUG

RUG -III Grouper Qualifications: Impaired Cognition and Behavior,

ADL

Impaired Cognition Impairment Defined

ADL=10 or LessOne of the 3 following criteria:1) Cognitive Impairment: A BIMS

interview score of less than or equal to 9 will meet the criteria for cognitive impairment.

2) C1000 Severely Impaired Decision Making (3)


Impaired Cognition Impairment Defined

3) Impaired CognitionTwo or more of the following impairment indicators are present

C0700 = 1 Short term memory problemC1000 > 0 Cognitive skills problemB0700 > 0 Problem being understood

ANDOne or more of the following severe impairment indicators are

present:C1000 >= 2 Moderately ImpairedB0700 >= 2 Sometimes understood



Care Planning for evidencing impaired cognitionOther conflicting assessments

Mini-Mental

Verification of Completion of BIMS in the 7-day look-back period

“If a staff member cannot sign Z0400 on the same day that he or she completed a section or portion of a section, when the staff member signs, use the date the item originally was completed”


Behavior Problem

ADL=10 or LessE0900 Wandering (2 or 3)E0200B Verbal Behavior Directed at others (2 or 3)E0200A Behavior Directed at others (2 or 3)E0200C Other Behavior not Directed at others (2 or 3)E0800 Resisted care (2 or 3)E0100C DelusionsE0100A Hallucinations


Documentation to Support Behavior

Documentation supports 4+Days in Look Back periodImpact on othersBehavior Monitoring sheets

NursingCNA

Social Services notes supportDaily Nursing notes


Additional Documentation

Care Planning evidencing behavior interventionPsychiatry and Psychological notes supportPhysician documentation


ADL Component of a RUG:

Highest Audit Reduction AreaImpacts all RUGRehab

RUCRML

Nursing:SE3-ADL minimum of 7


ADL Defining RUG Qualifier

RUG-IIIADL score of 7 or more Extensive and Special CareComa All ADL must be Dependent or did not occur (48)


BETT

Bed mobility (G0110A)Eating (G0110H)Transfer (G0110B)Toilet use (G0110I)


ADL Self Performance

Rules of 3Weight-bearing support 3 or more times Extensive AssistNon weight-bearing support 3 or more times code Limited Assist


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Supervision: Encouragement or cueing provided by the staffLimited Assistance: The resident received physical help in guided maneuvering of limbs or other non weight-bearing assistanceExtensive Assistance: The resident performed part of the activity and received assistance of the following types:

Weight-bearing support orFull staff assistance in the task/or portion of the task, during part but not all shift



7. Occurred 1 or 2 times8. Activity Did Not Occur during ENTIRE look back periodThe activity did not occur or family and/or non-facility staff provided careExamples:

The resident was on bed rest so transfer did not occur.The resident is non-ambulatory


Self Performance

The ENTIRE Look-back period:0. Independent: No staff assistance or supervision

New in MDS 3.0 Page G-6 Algorithm

4. Total Dependence: Full staff assistance of the entire activity each time it occurs. There was no participation by the residentComments on Audit not impacting RUG


ADL Support

ADL Support Provided: Code for the most support provided over the entire shift.

No Support Set up help onlyOne person physical assistTwo or more provided physical assistActivity itself did not occur during entire shift


RUG-III ADL-Step 1

Self-Performance Column 1 Support Column 2 ADL Score

7,0,1 Any number 1

2 Any number 3

3 2 4

4 2 4

8, 3 or 4 3, 8 5

Calculate for Bed Mobility, Transfer and Toilet Use


RUG-III ADL-Step 2

Self-Performance Column 1 Support Column 2 ADL Score

0,1 -,0, 1,8 1

2 2 2

3 2 3

4 2 3

Calculate for Eating


RUG-III ADL Nursing

Varies by Category (see Handout):Example Special Care

RUG-III ADL Score RUG-III Class 17 – 18 SSC

15 – 16 SSB 7 - 14 SSA


Documentation to Support ADL

CNA FlowsheetsReflect Month and Resident Name

Identify specific documentation utilized for 2 Assist provided by facility staff if single episode coded in the Look-back periodEnsure 3 episodes of assist are provided by facility staff are evident in the Look-back periodEnsure Dependent coded only if occurred during the entire look-back period


Questions/Answers

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